CASE
Fred is a 68-year-old man who has been married to Ethyl for approximately 2 years. He has 2 adult children who are estranged due in part to abuse they have received throughout their lives as a result of Fred's alcoholism. Ethyl, who is 62, owns her own home and has roughly $40,000 in savings which she has managed to accrue through the years that she has worked as a clerk at a local grocery store. Fred has no independent assets, has not been employed for a number of years, and has been in the hospital for approximately 2 months. He was admitted with a diagnosis of alcoholic encephalopathy. His course of treatment in the hospital has required mechanical ventilation among other things. He has difficulty swallowing as a result of his brain injury. He is currently deemed unable to make decisions by himself, although no legal guardian has been appointed. The psychiatric evaluation indicates that he may improve to the point that he can make decisions for himself in the future if he continues with treatment, but the medical evaluation indicates that nothing further can be done for him in this facility. The recommended course of treatment is discharge to a skilled nursing facility, but Ethyl objects to this as they require her to be responsible for payment of the cost of the care.
There are numerous healthcare providers involved in this case both because of the complexity of Fred's condition and the length of time of his hospitalization. Many of the healthcare providers involved are somewhat entrenched in their positions, in that they have decided "what's best" for Fred and are unhappy with Ethyl's refusal to agree with their position. They have requested a meeting of the interested parties to determine a course of conduct.
The hospital involved is a primary player in this drama. Census is consistently at capacity, the medical evaluation indicates that there is no further treatment to be provided, and Fred has no private insurance or resources from which to pay for his own care. The hospital is also concerned about forcibly discharging Fred home, as there is sufficient indication that this is an unsafe environment so as to potentially create liability if his postdischarge care falls below an acceptable standard or he meets an untoward accident.
The individual caregivers are important if somewhat inappropriate players, as they have to some extent attempted to usurp patient autonomy and decide on the "best" course of treatment for him. They have become embattled with Ethyl and discount her position and concerns as invalid, in part because of their view that she is somewhat culpable for having enabled Fred by purchasing alcohol for him or otherwise contributing to his poor health.
Ethyl is caught in a dual role. As the presumptive decision maker on Fred's behalf, she is charged with seeing to his best interest. She has made comments indicating that if she is forced to take him home against her wishes, she will stop and buy him a cheeseburger and a pint of whiskey on the way home which will undoubtedly result in aspiration and cause his return to the hospital.
Ethyl's concern is understandable. She is afraid that by committing Fred to a nursing home, she will quickly eat up her very meager savings and assets for his care. Virtually all of these assets were acquired while she was single and without Fred's assistance. She has supported him throughout their short marriage, and although she professes concern for Fred, her position is very much one of "I didn't sign up for this." She sees continued hospitalization as a cost-effective and acceptable plan.
ISSUES
What do we do with Fred?
The issue of allocation of resources is one that continually faces the healthcare system in the United States. There is a perception that all treatment should be freely available and that life should be prolonged in all cases, regardless of the cost.
As long as the immediate family does not experience out-of-pocket expenses, the tendency is to use more services, even when medical treatment is no longer appropriate. The hospital, recognizing that payment other than that given by Medicare is unlikely, would rather make the bed available to those patients who are either more likely to receive actual benefit from hospitalization or, alternatively, for those patients who are more likely to be able to pay for the services rendered either from their own resources or through insurance. Is consideration of the bottom line an appropriate item when determining a course of treatment for a patient? What should matter when making "stay or go" determinations? Culpability for the condition? Hospital census? Overall community needs? Age of the patient? Likelihood of recovery?
Although the individual healthcare providers may not be an appropriate party in this instance, they are frequently parties and are players in the unfolding drama. Because of the length of time they have cared for Fred, they feel somewhat invested in him and his recovery. Their empathy and caring nature may have somewhat jaded their perception, however, as there is a tendency to blame Ethyl for enabling Fred's alcoholism by providing the booze, while at the same time discounting Fred's responsibility for his alcoholism. Their bias is reflected in the positions that they adopt, and their lack of neutrality makes it more difficult to discuss an appropriate course of action. Should the healthcare provider's personal opinion weigh in on the treatment decision? In cases such as this, where there is an obvious disconnect between the goals of the decision maker and the needs of the patient, is it appropriate for a patient advocate to act as a de facto guardian to advocate either for the patient or the decider? When is it appropriate to go outside the system to ask that a separate legal guardian be appointed on behalf of the patient? Should that action ever be undertaken by a healthcare provider other than through the channels of the hospital administration?
Certainly, Ethyl is faced with difficult choices. Although it is easy to step back and "tsk tsk" her for the stops at the package store to supply Fred, it is also understandable that she was merely accommodating her husband. This is a second or subsequent marriage for each of them, and Ethyl did not anticipate that the little she had set aside to supplement her social security payments would be eliminated at such an alarming rate for Fred's care, especially when the prognosis for an extended and active life together is not good. Part of the dilemma comes from the fact that she wants what she perceives as best for Fred, but she also wants someone else to foot the bill for it. Is it appropriate that she should be homeless and impoverished for the next 20 years so that Fred can spend 18 months in a skilled nursing facility? Would it make a difference if Fred had contributed to the accumulation of these resources?
Like our public forums, this article is not designed to answer the questions. It is intended to cause each of us, either individually or collectively, to consider other points of view to better fulfill our obligations to our patients, to our professions, and to our employers.
Input? Feedback? Comments? We welcome anything you have to offer regarding this article or situations you have actually encountered that might make appropriate topics of discussion.
Section Description
Conversations in Ethics is an open forum hosted monthly by Catawba Valley Medical Center. A box lunch is provided free of charge to participants who meet to discuss a specific case that is distributed in advance. The program lasts from noon to 1:00 PM and is also open to the public. The purpose is to discuss ethical situations which confront healthcare providers and evaluate possible options and considerations available. The goal is not to provide a resolution to the situation, but rather to evaluate options available and gain perspective on common situations from various points of view. Please note that the situations presented here are fictional, although they are composites of various situations that have been encountered by the authors or other individuals providing background information or suggestions.